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No More Post-Colonoscopy Sticker Shock for Preventive CRC Screening

Thursday, February 21, 2013

One of the more positive aspects of the Patient Protection and Affordable Care Act is the provision requiring that preventive care must be covered at no out-of-pocket cost to patients, including co-pays and deductibles. Colorectal cancer screening advocates welcome this development. We all envisioned many people who would take advantage of this potentially life-saving procedure, if cost was no longer an issue.

However, some payors interpreted this provision to only apply if the colorectal cancer screening colonoscopy found no polyps that needed to be removed. Once a polyp was removed, and the procedure became a polypectomy, some payors applied the full range of copays and deductibles. Colorectal cancer screening advocates responded by pleading with the federal personnel responsible for the interpretation of the health insurance reform legislation and rules that his was in inappropriate application of the law. Those efforts have been rewarded.

The U.S. Department of Labor issues a Frequently Asked Question webpage that further addressed preventive care issues. Included in that page is the following:

“Q5: If a colonoscopy is scheduled and performed as a screening procedure pursuant to the USPSTF recommendation, is it permissible for a plan or issuer to impose cost-sharing for the cost of a polyp removal during the colonoscopy?

No. Based on clinical practice and comments received from the American College of Gastroenterology, American Gastroenterological Association, American Society of Gastrointestinal Endoscopy, and the Society for Gastroenterology Nurses and Associates, polyp removal is an integral part of a colonoscopy. Accordingly, the plan or issuer may not impose cost-sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost-sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service”

Thanks to this determination, patients covered by health insurance or self-funded plans will no longer face the prospect of needing to undergo this potentially life-saving procedure, but having no idea how much it would actually cost until the procedure was completed. Now all payors will have to cover a colorectal cancer screening colonoscopy as a preventive service, with no out of pocket expense to the patient. Preventing Colorectal Cancer applauds the Department of Labor for this determination.